RCM Questions one should ask while reviewing a medical billing company

Revenue Cycle Management (RCM) is the core process of any healthcare practitioner providing medical healthcare services. Trying to focus on how to turn around your practice to help it make the revenues is not an easy task. Although your patient is your first priority, coping with the changing rules & regulations can be a nightmare and cost you to lose a lot of revenue when claims are denied /rejected. And you have now come to the understanding, that healthcare is not just treating patients but it is a “business” to be run, something never taught in medical school.

The First step is to be sure that you wish to outsource the core process- RCM.  However, how does one go around Vetting Revenue Cycle Management Companies? Well, it’s not an easy task and can be as complex as handling the revenue of your practice. Before you go into posing RCM questions of the firm/vendor of any medical billing company, a few things you need to know are: find a company that employs certified technology approved by CMS and compatible with MU guidelines and who follows the accepted accounting practices and most importantly, is licensed to operate a business in your state.

Next step: Asking questions based on your practice needs and unique requirements.

Here are 5 crucial ones which are a must:

Query 1: Does their system profile patients unique to your practice?

Usually, when the Electronic Health Records (EHR) are monitored well, patient behavior can also be elicited. Physicians can thus know their patients better and thus implementing measures to follow up certain patients can be worked on helping you in the Value-based system of reimbursement.

Alongside this, do they have any ‘Patient Eligibility Verification’ services? This is actually the first step you need to verify. A mandatory process, which if not implemented can cost you a lot of missed revenue. How does their reporting app/platform help track the patient’s demographics and coverage?

Any dedicated teams to manage Patient support and a Patient portal that can help answer patient queries with respect to their insurance coverage and treatment required?

Query 2: Does the vendor/firm provide a summary of your current ‘Accounts Receivable’ (A/R)?

Your financial performance can get a boost only and when the Accounts Receivable meets its target. After submission of the medical claims to the insurance payer, how do their accounts receivable team track claims? Do they have anything in place that sends a red alert when the claims cross the 30-day bucket? What action/s do they take to pursue these?  In the case of an underpayment of claims, what steps do they take with the insurance company to ensure accurate processing and payment recovery?

Query 3: What are their Denial Management practices?

According to a HIMSS Analytics survey, most hospital executives, 44 percent, used RCM vendor solution to manage denials, 31 percent continued with the manual process, and 18 percent employed in-house created tools, but 7 percent were unsure about any denial practices that were required. It is a known fact that once claims are rejected nearly 80 percent are left unprocessed due to the long appeals process and the effort to get the documentation right.

Do they have certified coders as well as those who are updated with all the changes happening? When what modifiers are dropped or new ones introduced? Do they check consistently with the documentation provided? Most denials occur due to under coding or over coding that can hamper the inflow of your revenues. So check out in great detail how their denial management process works and if they have on record how denial management best practices/guidelines are followed.

Query 4: How good is their charge entry process?

 In order to ensure an effective Revenue Cycle Management process, the charge entry process should be efficiently run.  Getting the fact sheet of the patient dependent on how good the patient eligibility & verification process is; physician details- authorization, pre-authorization medical necessity documentation all met; information about the insurance coverage of the patient and the billing information.

This is the most vital process of any medical billing workflow. How efficient and effective this charge entry team is that – oversees the keyed in billing information, the appropriate codes entered and finally the analysis and investigation of the Explanation of Benefits (EOB) and checks received – should have a very tight and highly efficient working system.

Query 5: Are they meeting all Compliances required by the federal and state healthcare services?

The privacy and security of patient information is most critical. So when you hand over such information to a third-party you could become liable for legal issues if they do not implement certain compliant measures into their system. Ensuring that the RCM service provider is HIPAA( Health Insurance Accountability and Portability Act) compliant is of paramount importance. Privacy, security, and confidentiality of the protected health information (PHI) must be practiced rigorously.

Once you have the 5 critical queries checked out, then getting an analysis of their organization and recommendations/references should be the next step. Given the new rules for a number of audit reports to be submitted – this could also be one of the queries that could be part of your checking out, depending on your practice needs and requirements and in-house staff expertise.